Ewing sarcoma of the clavicle: a case series

Clavicle is a rare primary site for Ewing sarcoma (ES). We analyzed 4 patients with clavicular ES under our follow up and reviewed the literature on management of this rare tumor. All our patients were females with a median age of 16 years and were non metastatic at presentation. After a median follow-up of 21.5 months, 3 out of 4 patients are in complete remission. Clavicular ES in contrast to ES of other sites seems to have a female preponderance and outcomes are similar to non metastatic ES of other common sites.

Extra-skeletal Ewing's sarcoma in adults: presentation of two cases

Extraosseous Ewing's sarcoma represents about 5% of the Ewing family of tumours. Two cases in adult patients are presented, emphasizing the complexity of a multi-modality treatment approach of this tumour. Clinical presentation, chemotherapeutical, surgical and radiotherapeutical approaches are discussed. A thorough literature search was done to correlate our therapeutic attitude with current knowledge of this very rare disease.

Primitive neuroectodermal tumor/Ewing's sarcoma of the urinary bladder: a case report and its molecular diagnosis

We report a rare case of primitive neuroectodermal tumor/Ewing's sarcoma (PNET/ES) arising from the urinary bladder. A 65-year-old man presented with hematuria and dysuria. Computed tomography revealed an enlarged invasive tumor at the base of the bladder. No additional abnormal findings were disclosed by other diagnostic imaging methods. The surgical specimens showed small round cell tumor with positive staining for MIC2 gene product (CD99). EWS-FLI1 fusion transcripts were detected by reverse transcriptase polymerase chain reaction and direct sequencing, confirming the diagnosis of PNET/ES. The patient developed swollen pelvic lymph nodes as well as multiple lung metastases at 8 months postoperatively. No effective results could be obtained even with systemic chemotherapy consisting of vincristine, ifosfamide, doxorubicin and etoposide (VIDE) based on the EUROpean Ewing tumour Working Initiative of National Groups 1999 (EURO-E.W.I.N.G. 99) multinational trial. The patient died of acute superior mesenteric artery thrombosis at 22 months postoperatively. PNET/ES could have been included in past cases of small cell carcinoma because of the difficulty in its differential diagnosis. Exact diagnosis is crucial for deciding the treatment strategy for rare bladder tumors consisting of small round cells.

Serum metallothionein in newly diagnosed patients with childhood solid tumours

Tumour markers are substances produced by malignant cells or by the organism as a response to cancer development. Determination of their levels can, therefore, be used to monitor the risk, presence and prognosis of a cancer disease or to monitor the therapeutic response or early detection of residual disease. Time-consuming imaging methods, examination of cerebrospinal fluid or tumour tissue and assays for hormones and tumour markers have been used for cancer diagnosis. However, no specific marker for diagnosis of childhood solid tumours has been discovered yet. In this study, metallothionein (MT) was evaluated as a prospective marker for such diseases. Serum metallothionein levels of patients with childhood solid tumours were determined using differential pulse voltammetry - Brdicka reaction. A more than 5-fold increase in the amount of metallothionein was found in sera of patients suffering from cancer disease, compared with those in sera of healthy donors. The average metallothionein level in the sera of healthy volunteers was 0.5 ± 0.2 μmol · dm⁻³ and was significantly different (p<0.05, determined using the Schefe test) from the average MT level found in serum samples of patients suffering from childhood solid tumours (3.4 ± 0.8 μmol · dm⁻³). Results found in this work indicate that the MT level in blood serum can be considered as a promising marker for diagnostics, prognosis and estimation of therapy efficiency of childhood tumours.

Extra osseous primary Ewing's sarcoma

The case of 20 years old boy with an extra osseous Ewing's sarcoma is described. He was initially diagnosed as a case of infiltrative malignant tumour of left suprarenal gland on the basis of preoperative workup but postoperative biopsy of surgically excised specimen confirmed Extra-osseous Ewing's Sarcoma (EES) suprarenal gland with no evidence of malignancy on skeletal scintiscan, bone marrow aspirate and histopathology Suprarenal location of primary EES is unknown and probably has not been reported in literature. We report a unique case of EES.

[Ewing's sarcoma of bone:treatment results and prognostic factors]

OBJECTIVE

To determine the prognostic factors from the view of clinic and pathology.

METHODS

A retrospective analysis was performed on a data set of 78 patients with Ewing's sarcoma treated at Peking University People's Hospital Musculoskeletal tumor center between July 1998 and July 2007. Five-year overall survival (OS), recurrence rate and prognostic factors were analyzed in this study. Univariate and multivariate analysis were performed to determine the prognostic factors for OS.

RESULTS

Fifty-three cases were followed up, follow-up time ranged from 8.0 to 101.0 months (median 37.6 months). The 5-year overall survival rate and local recurrence rate were 33.7% and 20.8% respectively. Univariate showed age < 20 years, metastases free at diagnosis, tumor located at extremities, tumor size < 10 cm, adequate surgical margin had better survival rate (all P < 0.05). Multivariate analysis demonstrated that metastases at diagnosis, primary site and tumor size were independent prognostic factors for OS.

CONCLUSION

The independent prognostic factors Ewing's sarcoma are metastases at diagnosis, primary site, tumor size.

Decancellation sacral osteotomy in iliosacral tumor resection: a technique for precise sacral margins

En bloc resection of iliosacral sarcomas is a surgical challenge. There are substantial risks of inadequate margins, local recurrence, and nerve root loss when pelvic sarcomas involve sacral root canals and foramina. The decancellation technique uses principles similar to transpedicle decancellation in spinal deformity correction to perform the sacral osteotomy in iliosacral tumor resection. The technique aims at improving sacral margins and minimizing loss of neural function. We performed a decancellation osteotomy in five patients with sarcomas requiring difficult oblique or sagittal sacral osteotomies and selective root sacrifice. Through laminectomy and without anterior exposure, a precise full-thickness osteotomy of the sacrum was performed without major technique-related morbidities or complications. This was followed by formal pelvic resection and reconstruction. Surgical margins were adequate in all patients and all tumor-free nerve roots were preserved.

[Molecular pathological diagnosis of soft tissue tumors]

Among soft tissue tumors, which have some difficulties in diagnosis and treatment, it is known that distinctive chromosomal and gene abnormalities such as chromosomal translocations and fusion genes resulting from these translocations can be detected. We have focused on the research and development of split-signal DNA probes for FISH analysis, which can establish an accurate diagnosis by detecting the specific fusion genes for soft tissue tumors. Using these probes as well as commercially available probes, we conduct the FISH analysis on formalin-fixed, paraffin-embedded histological specimens to apply these methods to the routine pathological diagnosis. In this article, we introduce (1) principle of detecting fusion genes by RT-PCR and FISH, (2) outlines of FISH using split-signal probes, and (3) results of FISH analysis in Ewing sarcoma/PNET, rhabdomyosarcoma, pleomorphic liposarcoma and extraskeletal myxoid chondrosarcoma.

Extra-skeletal Ewing's sarcoma resembling acute abdomen. Case report

BACKGROUND

Extraosseous Ewing's sarcoma is a rare tumor of neuroectodermal origin. It presents mainly in the soft tissue of the extremities and thorax. Histologically, it is similar to Ewing's sarcoma of the bone.

CLINICAL CASE

We present the case of a male who arrived at the emergency room with acute abdomen, leucocytosis and imaging techniques (abdominal ultrasound and computed tomography) suggestive of complicated diverticular disease. He was treated with emergency surgery. Intraoperative findings were an unsuspected tumor (20 x 15 x 15 cm). Treatment consisted of extirpation of the tumor, separating it from the adjacent viscera and followed by chemotherapy based on epirubicin, cyclophosphamide and vincristine for six cycles. Because the control abdominal CT demonstrated tumor activity in the retroperitoneum adjacent to the ascending colon and cecum, further resection was decided upon.

CONCLUSIONS

In a review of the literature, no previous reports of extraosseous Ewing's sarcoma were found presenting as acute abdomen. Due to the rarity of this tumor, only case reports or series have been found in the literature without randomized or comparative studies. Surgery was the cornerstone of treatment, without reports of preoperative chemotherapy. If the patient's condition permits, percutaneous needle biopsy is mandatory to obtain optimum treatment as well as to improve prognosis.

Fibula stress fracture mimicking a malignancy

Stress fractures may be easily misdiagnosed as another entity, especially tumors, which may prompt very severe surgical treatment and sometimes amputation. The appropriate use of modern radiography may make the difference in proper diagnosis of stress fractures.

Cystic presentation of Ewing's sarcoma with indolent clinico-radiologic behaviour

Ewing's sarcoma is a high-grade malignant primary bone tumour with aggressive clinico-radiologic features. Rarely, it exhibits a benign pattern, but presentation as a solitary bone cyst in a long bone is rather unusual. The purpose of this paper is to document such a cystic presentation with relatively benign clinico-radiologic course and to review the pertinent literature. A 27-year-old male presented with a pathologic fracture through a radiologically benign appearing solitary bone cyst in the distal tibial metaphysis. The fracture healed on conservative treatment, but the patient presented again a year later with pain and difficulty with weight bearing. Curetting and bone grafting done elsewhere was suggestive of an Ewing's sarcoma, which was later confirmed by a second biopsy. He was treated by standard neoadjuvant chemotherapy followed by wide local excision and reconstruction with an intercalary allograft. At 2 years postoperative follow-up, the patient is without any evidence of local or distant recurrence. Awareness of this atypical presentation is important because it may help in an earlier diagnosis, avoid diagnostic confusion and thus may contribute to improved survival.

Intra-abdominal desmoplastic small round cell tumour in a 39-year-old man

Desmoplastic small round cell tumor is a very rare neoplasm, that usually appears in children and young adolescents. There is no standard therapy, and responses to chemotherapy are infrequent. Surgery is still the main treatment for this disease. We report the case of a 39 year-old man and briefly summarize the evidence about this tumor.

Primary bone lymphoma

Primary bone lymphomas are rare, even though secondary involvement of the bone marrow is a common event in systemic lymphomas. Most primary bone lymphomas are primary bone diffuse large B-cell lymphomas (PBDLBCLs) with a rare occurrence of follicular, marginal zone, anaplastic large cell, Hodgkin, and T-cell lymphomas. The PBDLBCL affects the middle-aged to elderly population, with a slight predominance in men. The patients present with bone pain, palpable mass, fractures, or neurologic symptoms. The metaphysis of bones is a common location of PBDLBCL. Morphologically, the lymphoma consists of a polymorphous mixture of small to large cells with multilobated nuclei, fine chromatin, and inconspicuous to prominent nucleoli. Differential diagnoses for PBDLBCL include chronic osteomyelitis, primary bone sarcoma, leukemic infiltrate, Ewing sarcoma, metastatic sarcomas, and carcinoma. Most PBDLBCLs are treated with combined radiotherapy and chemotherapy with good prognosis.

Prognostic value of immunohistochemistry in the Ewing's sarcoma family of tumors

BACKGROUND

The expressions of different markers have been immunohistochemically studied in various types of the Ewing's sarcoma family of tumors, especially for diagnostic purposes. However, little is known about their prognostic value in combination with the clinicopathological data of such patients.

MATERIAL/METHODS

This retrospective study investigated the immunohistochemical expressions of NSE, TdT, EMA, S-100, CK MNF116, p53, bcl-2, CD99, and CD117 on formalin-fixed paraffin-embedded material of 72 patients (age range: 2-59 years) with various types of Ewing's sarcoma family of tumors using the tissue microarray method. The immunohistochemical results were compared with clinicopathological features using survival analysis (Cox regression).

RESULTS

CD99 expression was detected in 90%, CD117 in 75.8%, bcl-2 in 70.1%, NSE in 66.6%, p53 in 66.6%, EMA in 26%, S-100 in 25.4%, TdT in 22.1%, and CK MNF116 in 10.2% of the cases. No immunoreactivity was observed in the normal tissue around the tumors.

CONCLUSIONS

The expressions of EMA (p=0.107), NSE (p=0.126), CD99 (p=0.14), TdT (p=0.198), bcl-2 (p=0.382), p53 (p=0.54), CD117 (p=0.612), S-100 (p=0.867), and CK MNF116 (p=0.934) had no statistically significant impact on survival. Patient age at the time of diagnosis (p=0.008) and the presence of tumor necrosis (p=0.033) were the only significant prognostic factors in this study. Tumor location was an insignificant prognostic factor (p=0.38).

[Adrenal incidentaloma: management approaches: CT - MRI]

The adrenal gland may be affected by several pathologies, and the detection of an adrenal nodule may occur during the work-up of a biological abnormality, oncologic work-up, or be incidental. Endocrinological and imaging work-up is required in all cases. Cross-sectional imaging has had a great impact on the diagnostic work-up of adrenal nodules. CT, without and with intravenous contrast, is the first line imaging study for evaluation of adrenal nodules. A spontaneous density below 10 HU confirms the benign nature of a nodule. When lesions cannot be characterized, postcontrast CT or MR imaging, including in and out of phase imaging, may allow diagnosis.

Extraskeletal Ewing's sarcoma

We report 2 rare cases of extraskeletal Ewing's sarcoma, one is arising primarily from the posterior mediastinum in a middle-aged man (patient 1), and the other one is arising from the left kidney in a young male patient (patient 2). The CT in the first case showed a large mass of heterogeneous texture, with areas of cystic changes in the right side of the posterior mediastinum, no underlying bony changes or intra-spinal extension, and this mass was diagnosed as lymphoma. The second case showed almost complete replacement of the left kidney by a mass with extension through the renal vein and inferior vena cava, and it was diagnosed as renal cell carcinoma. The histological analysis of these lesions revealed extraskeletal Ewing's sarcoma.

Primary vaginal extraosseous Ewing sarcoma/primitive neuroectodermal tumor with cranial metastasis

Extraosseous Ewing sarcoma is now regarded as a member of the Ewing sarcoma/primitive neuroectodermal tumor (PNET) family. It typically involves the soft tissues of the chest wall, pelvis, paravertebral region, abdominal wall, retroperitoneal region and extremities of children, adolescents and young adults, but it seldom occurs in the female genital tract. We report an extremely rare case of retrospective diagnosis of vaginal extraosseous Ewing sarcoma/PNET which metastasized to the right frontoparietal scalp, skull, and dura. Surgical resection, followed by adjuvant radiotherapy and chemotherapy resulted in a favourable clinical outcome. Both the vaginal and head tumors had similar light microscopic features supporting the diagnosis.

[Changes of 3-tesla 31P-MR spectroscopy of bone and soft tissue tumors]

OBJECTIVE

To study the characteristic changes of 31P-MR spectroscopy of bone and soft tissue tumors.

METHODS

41 patients were examined by phosphorus surface coil of 3 tesla MR machine, including 18 benign tumor foci and 28 malignant foci, and adjacent normal muscles. The areas under the peaks of various metabolites in the spectra were measured, including phosphomonoester (PME), inorganic phosphours (Pi), phosphodiester (PDE), phosphocreatine (Pcr), adenosine triphosphate (ATP) gamma, alpha, beta. The ratios of the metabolites to beta-ATP, NTP and Pcr were calculated. Intracellular pH was calculated according to the chemical shift change of Pi relative to Pcr.

RESULTS

The ratios of Pcr/PME and PME/NTP in benign and malignant tumor groups were significantly different from those of the normal group (P<0.05). Between benign and malignant tumor groups, the ratios of PME/beta-ATP and PME/NTP were significantly different (P<0.05).

CONCLUSION

Pcr/PME and PME/NTP are potential diagnostic indexes of bone and soft tissue tumors. PME/beta-ATP and PME/NTP are potential indexes of differential diagnosis of bone and soft tissue tumors.

Ewing's sarcoma/ primitive neuro-ectoclermal tumour: a case report

Ewing's sarcoma/primitive neuro-ectodermal tumour on medial end of the left clavicle is a rare site. Here is a case of 16-year-old female presented with gradually increasing swelling at medial end of clavicle, showing osteolytic lesion on x-ray and CT. Cytology showed features of Ewing's sarcoma, but histopathologically diagnosed as poorly differentiated small cell carcinoma. Marker study was carried out, and it confirmed Ewing's sarcoma. After 3 to 6 month of continuous therapy patient presented with axillary lymph node and skull vault metastasis, again a rare site for secondaries in Ewing's sarcoma.

Primitive neuroectodermal tumor as a differential diagnosis of CD56-positive tumors in adults

A 33-year-old Japanese man was referred to our hospital after a huge intrapelvic tumor with bilateral hydronephrosis was found following persistent lumbago. Natural killer/T-cell lymphoma was suspected due to positive immunostaining for CD56, but CHOP therapy was ineffective. Re-evaluation of the tumor cells showed that they were positive for CD99, neuron-specific enolase, and synaptophysin and had a t(11 ; 22) (q24 ; q12) translocation, leading to the revised diagnosis of primitive neuroectodermal tumor (PNET). Systemic chemotherapies and radiation therapy were added to surgical resection, and no recurrence has been detected for 3 years. Taken together, PNET may be considered in adult patients with CD56-positive tumors.

Conditions that mimic osteosarcoma

A variety of conditions may mimic osteosarcoma. The differential diagnosis includes benign and malignant tumors, infection and inflammatory processes arising from the musculoskeletal system. An accurate clinical history, imaging studies, and pathological evaluation are essential to establish the exact diagnosis. This chapter describes many of the conditions which may mimic the diagnosis of osteosarcoma. For convenience, the conditions are divided into several categories.

A clinico-pathologic correlation: primary Ewing's sarcoma of the mandibular body-ramus

A 15-year-old Asian male was referred to the department of oral and maxillofacial surgery at Tufts University School of Dental Medicine (TUSDM) for evaluation of a radiolucent lesion on the posterior left mandible. The patient was initially evaluated by his primary dentist for pain of two months' duration associated with teeth #17 and 18. Radiographic examination was performed and the panoramic radiograph revealed a radiolucent lesion involving the left mandibular body and ascending ramus, along with resorption of the roots of the predetermined teeth. Considering odontogenic infection, the patient was placed on antibiotics and referred to TUSDM for further evaluation and treatment.

New approaches in the diagnosis of small-cell round tumors of bone and soft tissue

The diagnosis of 17 small-cell round tumors of the bone and soft tissue, which were histologically similar to Ewing's sarcoma (EWS), was verified on paraffin sections, by using tissue microarray (TMA) technology, immunohistochemistry, cytogenetic (FISH) and molecular biological (RT-PCR) methods. Classical EWS was found to be in 8 patients, large-cell EWS in 1 patient; atypical EWS in 1, and endothelial ESW in 1. Two patients were diagnosed as having primitive neuroectodermal tumor (PNET), synovial sarcoma was present in 1 patient, embryonic rhabdomyosarcoma in 1, high-grade undifferentiated sarcoma in 1 and diffuse B-cell large-cell lymphoma in 1. TMA makes it possible to perform a number of diagnostic procedures on the same block containing a copious number of tumor samples and to assess the results of their use. It is emphasized that the diagnosis of small-cell round tumors requires the use of a package of the currently available methods providing the qualitative characteristics of each neoplasm.

Metastatic Ewing's sarcoma involving the right ventricle

Cardiac metastasis of Ewing's sarcoma is rare. A 22-year-old woman was admitted with complaints of palpitation and fatigue on exertion. She had a seven-year history of radical right tibial resection for Ewing's sarcoma and was also receiving chemotherapy for lung metastasis of Ewing's sarcoma. Both transthoracic and transesophageal echocardiography demonstrated a single, large (3x3.5 cm) inhomogeneous mass located in the free wall of the right ventricle. To differentiate the mass from a massive thrombus, contrast-enhanced magnetic resonance imaging was performed. The mass showed partial contrast enhancement, suggesting a malignant metastatic mass. Surgical resection was not considered due to accompanying lung metastasis and potentially poor outcome of the operation.

[Application of the in situ hybridization with EWS dual-color break-apart fluorescence probe and anti-CD99 and anti-FLI-1 antibodies in the diagnosis of Ewing's sarcoma/primitive neuroectodermal tumor]

OBJECTIVE

To investigate the value of using EWS dual-color, break-apart rearrangement probe fluorescence in situ hybridization (FISH) technique, CD99 and FLI-1 antibodies immunohistochemistry in the diagnosis of Ewing's sarcoma/primitive neuroectodermal tumor (EWS/PNET).

METHODS

Thirty-five cases of EWS/PNET and 24 cases of non-EWS/PNET small round cell tumor were analyzed by FISH and immunohistochemically detected with FLI-1 and CD99 antibodies. Comparison between FISH and immunohistochemical results was carried out and their diagnostic value was evaluated.

RESULTS

The sensitivity, specificity, positive predictive value and negative predictive value of FISH in EWS/PNET were 93.8%(30/32), 81.8%(18/22), 88.2%(30/34) and 90%(18/20); those of CD99 were 100%(35/35), 58.3% (14/24), 77.8%(35/45) and 100%(14/14); those of FLI-1 were 71.4%(25/35), 62.5%(15/24), 73.5%(25/34), 60%(15/25), respectively. The sensitivity, specificity, positive predictive value and negative predictive value of combined use of CD99 and FLI-1 were 71.4%(25/35), 75%(18/24), 80.6%(25/31) and 64.3%(18/28), those of combined use of FLI-1 and FISH were 68.7%(22/32), 86.4%(19/22), 88%(22/25) and 65.5%(19/29), those of combined use of CD99 and FISH were 93.7%(30/32), 95.5%(21/22), 96.8%(30/31) and 91.3%(21/23), respectively.

CONCLUSION

EWS dual-color, break-apart rearrangement probe FISH is a highly sensitive and specific technique in the diagnosis of EWS/PNET. The combination of CD99 and FISH is the method of choice for the diagnosis of EWS/PNET. The combination of CD99 and FLI-1 can improve the specificity in EWS/PNET without the data of FISH.

A comparision of RT-PCR and FISH techniques in molecular diagnosis of Ewing's sarcoma in paraffin-embedded tissue

Ewing's sarcoma is relatively uncommon tumor representing 6-8 percent of malignant bone tumors with variable morphology. Cytogenetically, Ewing's sarcomas are characterized by a specific reciprocal chromosomal translocation t(11;22)(q24;q12). The presence of this chromosomal translocation has been detected in approximately 85 percent of the cases. The translocation results in the fusion of EWS gene from chromosome 22 to FLI1 gene at 11q24 which is a member of ETS family of transcription factors. In this study we performed a comparison of two molecular diagnostic strategies, namely RT-PCR and FISH, in fresh, frozen and formalin-fixed paraffin-embedded tissues. We conclude that FISH is a more sensitive technique than RT-PCR for the diagnosis of Ewing's tumors in formalin-fixed paraffin-embedded tissue. In conclusion, molecular pathology techniques, using reverse transcription-polymerase chain reaction (RT-PCR) and/or fluorescence in situ hybridization (FISH) are valuable diagnostic tools for evaluation of undifferentiated small round-cell tumors like Ewing's sarcoma.

Ewing's sarcoma of the urogenital tract

This article reviews the current available information on Ewing's sarcoma of the urogenital tract, focusing on the presentation, diagnosis, and therapeutic management of this uncommon entity. Because of the rapid local growth of these tumors, an immediate decision for treatment initiation is mandatory. The classical presentation depends mainly on the site of involvement of these tumors, involving a palpable mass, hematuria, and pain. No specific diagnostic imaging is available to date, and the only diagnostic method remains histological examination in combination with immunohistochemistry. Treatment involves primary surgical resection of all tumor tissues followed by adjuvant multi-agent chemotherapy. Overall survival is poor, although a 13-year survival has been reached in one case.

[Late mediastinal metastasis of Ewing's sarcoma of tibia]

Peripheral neuroectodermal tumors constitute a large spectrum of small round cell tumors among which Ewing's sarcoma is the most undifferentiated type. They are rare tumors which often concern young people and generally occur in bone tissue. Their metastatic potential is high, generally early, and rarely after five years. We report the case of a 45-year-old woman who presented a mediastinal metastasis eight years after the primitive tumor of tibia. The diagnosis was made on small core biopsies obtained by CT punction, and was based on morphologic analysis, immunohistochemistry, and confirmed by molecular biology. The presence of metastasis is the main prognostic factor. Despite therapeutic progress, the global survival rate of metastatic patients is still poor.

A comparison of intramedullary and juxtacortical low-grade osteogenic sarcoma

While low-grade juxtacortical and low-grade intramedullary osteogenic sarcomas are histologically indistinguishable, they have been studied as separate entities. We retrospectively reviewed the clinical, radiographic, histologic features and treatment of 59 patients treated surgically to compare the rate of local recurrence, grade progression, and survival between low-grade intramedullary and low-grade juxtacortical osteogenic sarcoma. Forty-five (76%) patients were treated for low-grade juxtacortical osteogenic sarcoma and 14 (24%) were treated for low-grade intramedullary osteogenic sarcoma. Local recurrence rates of 7% were similar for both groups studied. The rate of distant metastases was also similar for both groups. . The rate of dedifferentiation for the entire group was 29%. Dedifferentiated lesions were treated with adjuvant chemotherapy in 16 of 17 cases. Recurrence preceded dedifferentiation in four cases. Five-year survival was over 90% in both groups. Low-grade intramedullary and low-grade juxtacortical osteogenic sarcoma were clinically indistinguishable with identical rates of local recurrence, distant metastases, dedifferentiation, and survival.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Ewing tumors in infants

BACKGROUND

Malignancies in infancy are extremely rare. Ewing tumors are hardly ever noted in these children. Since it is generally assumed that malignancies in infancy have an extremely poor outcome, we wanted to investigate whether this was also the case in Ewing tumors.

PROCEDURE

We identified in the Munster data bases of CESS81, CESS86, EICESS92 and EuroEwing99 14 children <12 months of age with a tumor of the Ewing family. Numbers of girls and boys were equal.

RESULTS

All infants had axial tumors, including pelvic primaries; 80% of the tumors were <200 ml. An uncommon pathology distribution was noted; the majority were peripheral neuroectodermal tumors, only two atypical Ewing, one classical Ewing, and one unspecified PAS positive small round blue cell soft tissue sarcoma was found. Three patients had metastatic disease at initial diagnosis. Treatment modalities were comparable with patients of older age. The number of cytostatic courses ranged from 6 to 15. Dose reductions were limited, ranged from 73% to 90%. Outcome results were similar to those in patients of older ages (5-year EFS 65%, OS 72%).

CONCLUSIONS

Infants with Ewing family tumors are in the majority of cases PNETs and are predominantly axial tumors. Outcome is similar to patients with Ewing tumors at older ages. Generally accepted adverse prognostic factors did not influence outcome.

SK-NEP-1 and Rh1 are Ewing family tumor lines

The utility of preclinical models of childhood cancers is contingent upon reliably classifying them with their corresponding clinical counterparts. Molecular tools such as gene expression profiling allow researchers to confirm the similarity between clinical tumors and preclinical models. We describe the use of gene expression profiling to show that SK-NEP-1, a cell line previously thought to represent anaplastic Wilms tumor, is instead related to Ewing sarcoma. RT-PCR confirmed that SK-NEP-1 expresses EWS-FLI1 gene fusion transcripts characteristic of Ewing sarcoma, and DNA sequencing demonstrated the joining of exon 7 of EWS with exon 5 of FLI1 for these transcripts. Rh1, which was previously categorized as an alveolar rhabdomyosarcoma cell line, also has a gene expression profile suggestive of Ewing sarcoma and expresses EWS-FLI1 fusion transcripts in which exon 7 of EWS is joined with exon 6 of FLI1. These examples illustrate the importance of molecularly characterizing pediatric preclinical models used for testing new agents.

Differential diagnosis of primary malignant bone tumors in the spine and sacrum. The radiological and clinical spectrum: minireview

Although primary malignant tumors of the spine and sacrum are described in all orthopedic textbooks, it is still remarkable how little attention is paid to differential diagnosis of persisting lower back pain and how to detect in special the underlying tumor disease. Chordoma, osteosarcoma, chondrosarcoma, plasmacytoma, lymphoma and Ewing's sarcoma, their radiological manifestation, age distribution and preferred location in the spine and sacrum are reviewed and discussed.

Ewing sarcoma/primitive neuroectodermal tumor of the kidney in a child

A 6-year-old female was admitted with abdominal pain and a mass in the right abdomen. Her lactose dehydrogenase level was 1,200 IU/L, and neuron specific enolase was 120 ng/ml. Computed tomography scan confirmed a large right renal mass with necrosis. A right radical nephrectomy was performed. The tumor was completely encapsulated. Based on small round cell histology, strong MIC-2 (CD99) positive tumor cells, and EWS-FLI-1 fusion transcript, Ewing sarcoma/primitive neuroectodermal tumor of the kidney was diagnosed. Induction and follow-up with seven cycles of chemotherapy were given after surgery. She has had no evidence of recurrence 90 months from diagnosis.

Ewing's sarcoma as second malignant neoplasm after retinoblastoma: a case report

OBJECTIVES

To report a case of a child with the hereditary form of unilateral retinoblastoma (RB), who developed Ewing's sarcoma of the right fibula 3 years after the enucleation of the right eye.

CASE PRESENTATION AND INTERVENTION

The child was diagnosed as a case of RB of the right eye at the age of 9 months. He was fully investigated and found to have locally advanced RB with bone marrow involvement (Reese-Ellsworth stage IVA). Enucleation was recommended to the family, but they refused. The patient received chemotherapy and diode laser thermotherapy in Kuwait and the UK. He had a local relapse after 11 months and subsequently underwent enucleation of the right eye. After 3 years, he was investigated for a small swelling in his right lower leg. After extensive investigations, it was reported as Ewing's sarcoma. He was treated with chemotherapy, surgery (complete excision of the fibula) and high-dose chemotherapy followed by autologous stem cell transplantation. The child is now nearly 2 years after completing the treatment and is disease free.

CONCLUSIONS

This case confirms the increased risk of a second malignant neoplasm (SMN) in children with hereditary RB. These children need a very close follow-up for the early diagnosis of SMNs or even subsequent malignancies.

Short telomeres: a novel potential predictor of relapse in Ewing sarcoma

PURPOSE

Despite advances in therapy, >50% of patients with Ewing sarcoma will relapse. The current prognostic factors are not optimal for risk prediction. Studies have shown that telomere length could predict outcome in different malignancies. Our aim was to evaluate whether telomere length could be a better prognostic factor in Ewing sarcoma and correlate the results with clinical variables, outcome, and chromosomal instability.

EXPERIMENTAL DESIGN

Telomere length was determined in the primary tumor and peripheral blood of 32 patients with Ewing sarcoma. Chromosomal instability was evaluated by combining classical cytogenetics, comparative genomic hybridization and random aneuploidy. Telomere length was correlated to clinical variables, chromosomal instability, and outcome.

RESULTS

In 75% of the tumors, changes in telomere length, when compared with the corresponding peripheral blood lymphocytes, were noted. The majority of changes consisted of a reduction in telomere length. Patients harboring shorter telomeres had a significantly adverse outcome (P = 0.015). Chromosomal instability was identified in 65% of tumors, significantly correlating with short telomeres (P = 0.0094). Using multivariate analysis, telomere length remained the only significant prognostic variable (P = 0.034). Patients with short telomeres had a 5.3-fold risk of relapse as compared to those with unchanged or longer telomeres.

CONCLUSION

We have shown that tumors with telomere length reduction result in genomic instability. In addition, telomere length reduction was the only significant predictor of outcome. We suggest that reduction of telomere length in tumor cells at diagnosis could serve as a prognostic marker in Ewing sarcoma.

Treatment of metastatic Ewing sarcoma/primitive neuroectodermal tumor of bone: evaluation of increasing the dose intensity of chemotherapy--a report from the Children's Oncology Group

BACKGROUND

The outcome for patients with Ewing sarcoma family of tumors (ESFTs) of bone with metastases at diagnosis remains poor despite new approaches to treatment. We evaluated whether a dose-intensity chemotherapy regimen improved survival for patients with ESFTs of bone with metastases at diagnosis.

METHODS

We entered 60 patients with metastatic ESFTs of bone onto a single arm trial of a new intensive therapy. Treatment consisted of 51-weeks of chemotherapy and local control of the primary with radiation, surgery, or both. The chemotherapeutic protocol included two alternating blocks: one with vincristine (2 mg/m(2)), doxorubicin (90 mg/m(2)), and cyclophosphamide (2,200 mg/m(2)); and the second with ifosfamide (2,800 mg/m(2)/day x 5 days) and etoposide (100 mg/m(2)/day x 5 days).

RESULTS

Of the 60 patients with metastatic ESFTs of bone enrolled onto this single arm trial, 12 had metastasis to lung only, 7 to bone marrow or bone only, 38 to multiple sites, 2 in other sites and 3 not specified. There were three toxic deaths. Six patients (6-year cumulative incidence: 9%) developed second malignant neoplasms and died. The 6-year overall event-free survival (EFS) was 28% (standard error (SE) 6%) and survival (S) was 29% (SE 6%).

CONCLUSION

An intensified treatment regimen using higher doses of cyclophosphamide, ifosfamide, and doxorubicin increased toxicity and risk of second malignancy without improving EFS and S.

Leydig cell tumor after treatment for Ewing's sarcoma

Leydig cell tumors account for 3% of testicular tumors and have never been reported after treatment for Ewing's sarcoma. We report the unusual occurrence of a patient who developed a Leydig cell tumor of the testis 18 years after successful treatment for Ewing's sarcoma. Additional monitoring for second malignancies may become appropriate as long-term survival continues to improve for patients with Ewing's sarcoma.